Lessons Learned from Routine Intraoperative Ureteral Margin Frozen Sections during Radical Cystectomy

We examined the practice patterns of intraoperative ureteral frozen section during radical cystectomy and the impact of ureteral margin positivity on operative characteristics and oncologic outcomes.

The records of patients who underwent radical cystectomy at our institution from 2004 to 2011 were identified. Intraoperative ureteral frozen section characteristics were examined, including number, laterality, positivity, conversion to negative and final permanent section status. Logistic regression analysis was performed for predictors of operative time, change in urinary diversion, and biopsy confirmed upper tract recurrence and metastasis.

A total of 590 intraoperative ureteral frozen sections were sent for analysis from 241 patients (mean age 69 years). The sections were positive in 12.9% of cases and conversion to negative was accomplished in 82%. Multiple sections were associated with longer operating time (561 vs 511 minutes, p=0.011). Sensitivity for the sections was 100% and specificity was 93.6%. Taking multiple ureteral resections did not alter the planned urinary diversion in any patient or increase perioperative complication rates. At a mean followup of 22±19.8 months, 7 patients (3%) experienced upper tract recurrence. Intraoperative ureteral frozen section conversion to negative was associated with improved overall survival but not with upper tract recurrence.

Our practice of taking intraoperative ureteral frozen sections provided excellent sensitivity and specificity, and the prolonged operative time did not translate into increased perioperative complications. Conversion of positive to negative was associated with improved overall survival, independent of patient comorbidities and post-operative complications. No association was seen with upper tract recurrence but this was likely due to our high conversion rate to negative margins (82%), negative permanent section ureteral margin status in 97% of cases and the long followup time needed to demonstrate an association.